Organized and motivated registered nurse eager to utilize all skills acquired to enhance your company’s impact on the clients serviced. Over 20 years of experience in Utilization Review supporting varies healthcare organizations. Skilled at working in a fast-paced environment adapting to new situations and challenges to meet the department’s needs.
Overview
27
27
years of professional experience
1
1
Certification
Work History
UTILIZATION REVIEW NURSE (REMOTE)
American Health Partner - Plans
Franklin, TN
08.2021 - Current
Provide utilization review for Medicare members.
Reviews clinical documentation for medical necessity with use of InterQual and Centers for Medicare & Medicaid Services (CMS) criteria.
The utilization review process is conducted for outpatient /inpatient surgeries ,procedures, Durable Medical Equipment (DME), ambulance transport, Occupational, Speech, Physical Therapy , Home Healthcare, Wound Care, Out of network office visits, RX Injections and IV infusions .
Referrals made to the Medical Director for a determination of authorization request which do not meet the IQ and CMS Criteria.
UTILIZATION REVIEW NURSE (REMOTE)
CIGNA Health Springs
Bedford, TX
04.2020 - 05.2021
Provided utilization review for Medicaid Star Plus managed Care Program.
Clinical records reviewed for medical necessity with use of InterQual criteria for Outpatient services, Inpatient admissions, Concurrent review ,Skilled Nursing Facilities (SNF),Acute Rehabilitation and Long term care facilities(LTAC).
Referred to the Medical Director review authorization request which did not meet InterQual criteria.
Referrals made for Case Management and Behavioral Health services. Collaborated with the utilization review team in a weekly meeting to facilitate discharge planning and find solutions to barriers of discharge.
REGISTERED NURSE CASE MANAGER
Christus Health
Irving, TX
11.2017 - 07.2018
Worked with physicians and Multidisciplinary team members to develop a plan of care for each assigned patient from admission through discharge.
Ensured patient progression towards desired outcomes by continuous monitoring patient care through assessments and/ or evaluations.Assessment and response to patient/family needs by coordinating efforts of other team members.
Barriers were identified and resolved that would hinder effective patient care.
RN CASE MANAGER /CM SUPERVISOR (Satellite Office)
Arkansas Blue Cross and Blue Shield/USABLE
Dallas, TX
07.2012 - 11.2015
Case Manager for specific client population initiating a collaborative process which assessed,planned, implemented,coordinated,monitored and evaluated the options and services required to meet an individual's health needs, utilized plan benefits and community resources.
Available resources were used to promote quality and cost effective outcomes to benefit the members.
As a Case Management Supervisor I coordinated and worked with Case mangers and Pre-Cert Nurses to establish efficient processes, work flows and assessed the level of of staffing available to respond to daily needs.
This role worked closely with the Medical Affairs Manager, Medical Affairs Director and Medical Director for the implementation of medical Management programs across all lines of business.
REGISTERED NURSE UTILIZATION REVIEW PRE-CERT
Health Smart / Pre-certification Company
Irving, TX
04.2006 - 01.2008
Performed Pre-certification of hospital admissions,outpatient surgery,DME and other services.
Provided education of internal as well as external customers of the manage care process.
If clinical did not meet Milliman criteria a referral was sent to the Medical Director for a review and determination
REGISTERED NURSE EMERGENCY ROOM CASE |MANAGER
Baylor Scott & White Medical Center
Irving, TX
04.2006 - 01.2008
Facilitated patient continuity of care with the health care team.
Used criteria such as ( InterQual/ TMF) resources to performed utilization review of admission and communicated with third party payers.
Prepared for discharged planning at the start of admission and worked as patient/family advocated /liaison for any specific questions or concerns as it related to care planning , insurance authorization , available in-network options for providers such as Home Healthcare/DME providers.
Collaborated with the social worker team to insure the patient had access to needed resources available prior to discharge.
PRECERTIFICAIOTN INTERACT NURSE
CIGNA HEALTH PLAN /INTRA-CORP (UR Company)
Plano, TX
11.2002 - 05.2005
Performed Pre-certification of hospital admissions, outpatient surgery, injectable medications, DME and other services.
Provided education of internal as well as external customers of the manage care process and the available benefits.
Interact Nurse - Presented clinical information which did not meet criteria guidelines to the medical directors for review.
Utilization Management Nurse Consultant
Aetna US Healthcare
Dallas, TX
08.1996 - 10.2002
A liaison between provider groups in managing and coordination of health care services.
Primary responsibilities include pre-certification, concurrent review, discharge planning, case management, training and development of new nurses.
Presented clinical information which did not meet criteria guidelines to the medical directors for review.
Collaborated with provider relations department for out of network needs.
Education
Nursing
Mississippi College
Clinton, MS
05-1985
Skills
Utilization Review Experience with hospitals and insurance companies
Experience with InterQual and Milliman Criteria
Experience with Plan polices ,Coverage Bulletins and State Mandates
Experience with Centers for Medicare (CMS ) Criteria
Experience with Epic Systems
Experience with HCPCS / CPT codes and Modifiers
Experience with ICD 10 Codes
Experience in writing policy's and procedures
Excellent prioritization , organization and time management
Detail , Goal, Results and meeting deadlines oriented
Great listening and Communication skills
Great problems solving and Critical thinking skills
Excellent Liaison , collaborative and establishing rapport skills
Case Management experience with hospitals and Insurance Companies
Certification
Registered Nurse , BSN
Certified Case Manager
Timeline
UTILIZATION REVIEW NURSE (REMOTE)
American Health Partner - Plans
08.2021 - Current
UTILIZATION REVIEW NURSE (REMOTE)
CIGNA Health Springs
04.2020 - 05.2021
REGISTERED NURSE CASE MANAGER
Christus Health
11.2017 - 07.2018
RN CASE MANAGER /CM SUPERVISOR (Satellite Office)
Arkansas Blue Cross and Blue Shield/USABLE
07.2012 - 11.2015
REGISTERED NURSE UTILIZATION REVIEW PRE-CERT
Health Smart / Pre-certification Company
04.2006 - 01.2008
REGISTERED NURSE EMERGENCY ROOM CASE |MANAGER
Baylor Scott & White Medical Center
04.2006 - 01.2008
PRECERTIFICAIOTN INTERACT NURSE
CIGNA HEALTH PLAN /INTRA-CORP (UR Company)
11.2002 - 05.2005
Utilization Management Nurse Consultant
Aetna US Healthcare
08.1996 - 10.2002
Nursing
Mississippi College
Registered Nurse , BSN
Certified Case Manager
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